The Naked Surgeon: The Power and Peril of Transparency in Medicine

By Samer Nashef

In British medical schools in the ’70s, students were attached to ‘firms’ for varying periods, usually of a few weeks. Firms were hospital sub-units made of a pair or a trio of senior doctors, or ‘consultants’, working in one specialty. […] We were each allocated a topic to read about, and we were required to give a short talk on the chosen topic to a small and select assembly consisting of the firm surgeons, professor, and lecturers, as well as our fellow students.

My assigned topic was ‘emergency arterial surgery’, which sounded pretty exotic. I managed to find two examples of such surgery. The first was a ‘femoral embolectomy’, the removal of a blood clot from the main artery to the leg. This is what happens: A patient with a problematic heart gets a blood clot in it. As the heart beats, the clot becomes detached (in medical parlance, it becomes an ‘embolus’, or roving clot) and travels out of the heart and down the body until it gets stuck in the femoral artery, the large blood vessel that feeds the leg. The leg becomes cold, white, and painful, and, unless the clot is quickly removed by femoral embolectomy, the leg dies and drops off, or has to be amputated. Now that is drastic surgery, but it is quite tame when compared with the second example I found: repair of a ruptured ‘abdominal aortic aneurysm’ (or ‘triple A’).

The aorta is the biggest artery in the body, with the calibre of a large hosepipe. It comes out of the top of the heart, curves back like an old-fashioned walking stick, and descends through the chest towards the belly and the legs, giving branches along the way that feed every single part of the body. Sometimes, the wall of the aorta, as it passes through the belly, is weakened by age and disease. Under the relentless high pressure of the blood within it, it begins to stretch out into a balloon, or ‘aneurysm’. Eventually, it suffers the inevitable fate of most balloons: it bursts. When this particular balloon bursts, the patient either dies suddenly or becomes very sick, in shock, with lots of blood and clots in the belly, and, unless an emergency operation is done immediately to replace the blown bit of aorta with a watertight plastic tube, death is certain.

I began my research by visiting the library to find out more about ruptured triple A: what causes it, who gets it, what its symptoms are, how it is fixed, and what percentage of patients survive. I quickly discovered that, despite treatment by emergency surgery, about half the patients died. It occurred to me that I might find some individual patient stories with which to enliven my talk, and to look at the experience with this operation locally. At the time, not much had been written about this rare condition, so, being rather ambitious, I resolved to study all cases of ruptured triple A treated in the hospital in the previous ten years.

I summarised all the patient features, the findings at operation, and the outcomes of these operations. I then analysed the results with an eye to what determines a successful outcome: survival. I was taken aback to discover that all of my hypotheses for important factors in survival were simply wrong. I had assumed that unduly delayed diagnosis would lead to death. It didn’t. I had guessed that unduly delayed treatment would lead to death. It didn’t. I had thought that older and sicker patients, or those whose kidneys had shut down, were more likely to die. They weren’t.

Two factors alone predicted the outcome. The first was how badly the patient was in shock on arrival at the hospital: those who arrived cold and clammy with a fast heart rate and a low blood pressure did badly, and those who were pink at the edges with good circulation and a normal blood pressure did well. The second factor was who did the operation. To my astonishment, the best results had been achieved by a pair of surgeons with a special interest in breast and thyroid surgery, and the worst results by the firm that actually specialised in arteries, which was — you guessed it — the very firm of surgeons to which I was attached. As for the causes of death, they were varied, but, on post-mortem examination, more than half were found to have had technical problems, such as bleeding from the stitch lines.

This was dynamite! How was it possible that the surgeons who should have been the best at this operation were actually the worst? What was going on?